Gonorrhea medical therapy: Difference between revisions

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==Medical Therapy==
==Medical Therapy==
*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].
*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].
*Gonorrhea treatment is complicated by the ability of ''[[Neisseria gonorrhoeae]]'' to develop resistance to [[antimicrobials]]; accordingly, a combination therapy with [[Azithromycin]] and a [[cephalosporin]] is used to improve treatment efficacy and potentially slow the emergence and spread of resistance.
*Gonorrhea treatment is complicated by the ability of ''[[Neisseria gonorrhoeae]]'' to develop resistance to [[antimicrobials]]; accordingly, a combination therapy with [[Azithromycin]] and a [[cephalosporin]] is used to improve treatment efficacy and potentially slow the emergence and spread of resistance.
*[[Ceftriaxone]] and [[cefixime]] exist as the last remaining options for empirical first-line treatment of ''[[Neisseria gonorrhoeae]]''.<ref name=CDC-Guidline> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>
*[[Ceftriaxone]] and [[cefixime]] exist as the last remaining options for empirical first-line treatment of ''[[Neisseria gonorrhoeae]]''.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>


{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
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! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 450px;" | {{fontcolor|#FFF|Regimen}}
! style="background: #4479BA; width: 450px;" |{{fontcolor|#FFF|Regimen}}
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Uncomplicated Recommended regimen'''
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Recommended regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |<br />
*[[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose  
 
* [[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
 
* For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
* [[Chlamydial]] co-infection:
** add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
* [[Gentamicin]] 240 mg IM as a single dose plus [[azithromycin]] 2 g orally as a single dose OR
*Test of cure should be performed after 1 week
 
* [[Cefixime]] 800 mg orally as a single dose.
 
(Add [[doxycycline]] 100 mg orally twice daily for 7 days f [[Chlamydia infection|chlamydial]] infection has not been excluded)
 
(During [[pregnancy]], [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia.
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Alternative regimens for severe Cephalosporin allergy'''
| style="padding: 5px 5px; background: #DCDCDC;" |'''Alternative regimens for severe Cephalosporin allergy'''
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
*[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
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*Test of cure should be performed after 1 week
*Test of cure should be performed after 1 week
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #DCDCDC;" |'''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
Line 37: Line 48:
*[[Ceftizoxime]] 1 g IV q8h  for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose (alternative)
*[[Ceftizoxime]] 1 g IV q8h  for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose (alternative)
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #DCDCDC;" |'''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1-2 g IV  q 12-24 h  for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
*[[Ceftriaxone]] 1-2 g IV  q 12-24 h  for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
|}
|}


===Antimicrobial Regimen===
===Antimicrobial Regimen===
:* '''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
 
::* 1. '''Gonococcal infections in adolescents and adults'''
:*'''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
:::* 1.1 '''Uncomplicated gonococcal infections of the cervix, urethra, and rectum'''
::*1. '''Gonococcal infections in adolescents and adults'''
::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
:::*1.1 '''Uncomplicated gonococcal infections of the cervix, urethra, and rectum'''
::::* Alternative regimen: [[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose (if ceftriaxone is not available)
::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
:::* 1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::*Alternative regimen: [[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose (if ceftriaxone is not available)
::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
:::*1.2 '''Uncomplicated gonococcal infections of the pharynx'''
:::::* 1.2.1 '''Management of sex partners'''
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::::* Expedited partner therapy: [[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::** For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::::* Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.  
::::** for chlamydia co-infection add doxycycline 100 mg orally twice a day for 7 days. (During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia)
::::::* Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.  
::::** No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
::::::* Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
:::::*1.2.1 '''Management of sex partners'''
:::::* 1.2.2  '''Allergy, intolerance, and adverse reactions'''
::::::*Expedited partner therapy: [[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::* Preferred regimen (1): [[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::*Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
::::::* Preferred regimen (2): [[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::*Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::::* Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
::::::*Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
:::::* 1.2.3 '''Pregnancy'''
:::::*1.2.2  '''Allergy, intolerance, and adverse reactions'''
::::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Preferred regimen (1): [[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
:::::* 1.2.4 '''Suspected cephalosporin treatment failure'''
::::::*Preferred regimen (2): [[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
::::::* Alternative regimen (1): [[Gemifloxacin]] 320 mg PO  single dose  {{and}} [[Azithromycin]] 2 g PO  single dose (when isolates have elevated cephalosporin MICs)
:::::*1.2.3 '''Pregnancy'''
::::::* Alternative regimen (2): [[Gentamicin]] 240 mg IM  single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::* Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
:::::*1.2.4 '''Suspected cephalosporin treatment failure'''
::::::* Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
:::* 1.3 '''Gonococcal conjunctivitis'''
::::::*Alternative regimen (1): [[Gemifloxacin]] 320 mg PO  single dose  {{and}} [[Azithromycin]] 2 g PO  single dose (when isolates have elevated cephalosporin MICs)
::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (2): [[Gentamicin]] 240 mg IM  single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::: Note: Consider one-time lavage of the infected eye with saline solution.
::::::*Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
:::::* 1.3.1 '''Management of sex partners'''
::::::*Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
::::::* Patients should be instructed to refer their sex partners for evaluation and treatment.  
:::*1.3 '''Gonococcal conjunctivitis'''
:::* 1.4 '''Disseminated gonococcal infection'''
::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
:::::* 1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
:::::Note: Consider one-time lavage of the infected eye with saline solution.
::::::* Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
:::::*1.3.1 '''Management of sex partners'''
::::::* Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
::::::*Patients should be instructed to refer their sex partners for evaluation and treatment.
::::::* Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h  for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
:::*1.4 '''Disseminated gonococcal infection'''
:::::* 1.4.2 '''Gonococcal meningitis and endocarditis'''
:::::*1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
::::::* Preferred regimen: [[Ceftriaxone]] 1-2 g IV  q 12-24 h  for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::* 2. '''Gonococcal infections among neonates'''
::::::*Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
:::* 2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::::*Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h  for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::::* Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*1.4.2 '''Gonococcal meningitis and endocarditis'''
:::::* 2.1.1 '''Management of mothers and their sex partners'''
::::::*Preferred regimen: [[Ceftriaxone]] 1-2 g IV  q 12-24 h  for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::* Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
::*2. '''Gonococcal infections among neonates'''
:::* 2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
:::*2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::* Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days  
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
::::* Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV  q12h for 7 days.
:::::*2.1.1 '''Management of mothers and their sex partners'''
::::* Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::::*Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
::::* Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::*2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
:::::* 2.2.1 '''Management of mothers and their sex partners'''
::::*Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::::* Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
::::*Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV  q12h for 7 days.
:::* 2.3 '''Neonates born to mothers who have gonococcal infection'''
::::*Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::* Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
::::*Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::::* 2.3.1 '''Management of mothers and their sex partners'''
:::::*2.2.1 '''Management of mothers and their sex partners'''
::::::* Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::::::*Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
::* 3. '''Gonococcal infections among infants and children'''
:::*2.3 '''Neonates born to mothers who have gonococcal infection'''
:::* 3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
::::* Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.3.1 '''Management of mothers and their sex partners'''
:::* 3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::::*Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1g PO in a single dose
::*3. '''Gonococcal infections among infants and children'''
::::* Alternative regimen: [[Cefixime]] 400 mg PO  single dose {{and}} [[Azithromycin]] 1 g PO single dose.(If ceftriaxone is not available)
:::*3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
:::* 3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
::::* Preferred regimen: [[Ceftriaxone]] 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
:::*3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
:::* 3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1g PO in a single dose
::::* Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days
::::*Alternative regimen: [[Cefixime]] 400 mg PO  single dose {{and}} [[Azithromycin]] 1 g PO single dose.(If ceftriaxone is not available)
:::*3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
:::*3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days
 
===Follow-Up===
===Follow-Up===
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name=CDC-Guidline> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>
 
*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
*Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated

Revision as of 12:32, 21 August 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Overview

The mainstay of therapy for gonococcal infections is antimicrobial therapy. Gonorrhea treatment is complicated by the ability of N. gonorrhoeae to develop resistance to antimicrobials; accordingly, a combination therapy with Azithromycin and a cephalosporin is used to improve treatment efficacy and potentially slow the emergence and spread of antibiotic resistance.[1]

Medical Therapy

Type of gonococcal infection Regimen
Uncomplicated Recommended regimen
  • Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
  • For persons weighing ≥150 kg (300 lb), 1 g of IM ceftriaxone should be administered.
  • Chlamydial co-infection:
    • add doxycycline 100 mg orally twice daily for 7 days. (azithromycin 1 g as a single dose is recommended to treat chlamydia During pregnancy)
Uncomplicated Alternative regimen
  • Cefixime 800 mg orally as a single dose.

(Add doxycycline 100 mg orally twice daily for 7 days f chlamydial infection has not been excluded)

(During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia.

Alternative regimens for severe Cephalosporin allergy
Arthritis and arthritis-dermatitis syndrome
Gonococcal meningitis and endocarditis

Antimicrobial Regimen

  • Neisseria gonorrhoeae treatment[3]
  • 1. Gonococcal infections in adolescents and adults
  • 1.1 Uncomplicated gonococcal infections of the cervix, urethra, and rectum
  • Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
  • Alternative regimen: Cefixime 400 mg PO in a single dose AND Azithromycin 1 g PO in a single dose (if ceftriaxone is not available)
  • 1.2 Uncomplicated gonococcal infections of the pharynx
  • Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
    • For persons weighing ≥150 kg (300 lb), 1 g of IM ceftriaxone should be administered.
    • for chlamydia co-infection add doxycycline 100 mg orally twice a day for 7 days. (During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia)
    • No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
  • 1.2.1 Management of sex partners
  • Expedited partner therapy: Cefixime 400 mg PO in a single dose AND Azithromycin 1 g PO in a single dose
  • Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
  • Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
  • Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
  • 1.2.2 Allergy, intolerance, and adverse reactions
  • Preferred regimen (1): Gemifloxacin 320 mg PO in a single dose AND Azithromycin 2 g PO in a single dose
  • Preferred regimen (2): Gentamicin 240 mg IM in a single dose AND Azithromycin 2 g PO in a single dose
  • Note: Use of Ceftriaxone or Cefixime is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
  • 1.2.3 Pregnancy
  • 1.2.4 Suspected cephalosporin treatment failure
  • Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
  • Alternative regimen (1): Gemifloxacin 320 mg PO single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
  • Alternative regimen (2): Gentamicin 240 mg IM single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
  • Alternative regimen (3): Ceftriaxone 250 mg IM as a single dose AND Azithromycin 2 g PO as a single dose (failure after treatment with Cefixime and Azithromycin)
  • Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
  • 1.3 Gonococcal conjunctivitis
Note: Consider one-time lavage of the infected eye with saline solution.
  • 1.3.1 Management of sex partners
  • Patients should be instructed to refer their sex partners for evaluation and treatment.
  • 1.4 Disseminated gonococcal infection
  • 1.4.1 Arthritis and arthritis-dermatitis syndrome
  • 1.4.2 Gonococcal meningitis and endocarditis
  • 2. Gonococcal infections among neonates
  • 2.1 Ophthalmia neonatorum caused by N. gonorrhoeae
  • Preferred regimen: Ceftriaxone 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
  • 2.1.1 Management of mothers and their sex partners
  • Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
  • 2.2 Disseminated gonococcal infection and gonococcal scalp abscesses in neonates
  • Preferred regimen (1): Ceftriaxone 25-50 mg/kg/day IM/IV q24h for 7 days
  • Preferred regimen (2): Cefotaxime 25 mg/kg IM/IV q12h for 7 days.
  • Note (1): The duration of treatment is 10-14 days if meningitis is documented.
  • Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
  • 2.2.1 Management of mothers and their sex partners
  • Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
  • 2.3 Neonates born to mothers who have gonococcal infection
  • Preferred regimen: Ceftriaxone 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
  • 2.3.1 Management of mothers and their sex partners
  • Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
  • 3. Gonococcal infections among infants and children
  • 3.1 Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis
  • Preferred regimen: Ceftriaxone 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
  • 3.2 Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis
  • Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1g PO in a single dose
  • Alternative regimen: Cefixime 400 mg PO single dose AND Azithromycin 1 g PO single dose.(If ceftriaxone is not available)
  • 3.3 Children who weigh ≤ 45 kg and who have bacteremia or arthritis
  • Preferred regimen: Ceftriaxone 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
  • 3.4 Children who weigh > 45 kg and who have bacteremia or arthritis
  • Preferred regimen: Ceftriaxone 1 g IM/IV q24h for 7 days

Follow-Up

A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with pharyngeal gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or NAAT. If the NAAT is positive, effort should be made to perform a confirmatory culture before commencing retreatment.[2]

  • All positive cultures for test-of-cure should undergo antimicrobial susceptibility testing
  • Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
  • If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment

References

  1. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  2. ↑ 2.0 2.1 Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016
  3. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.


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